When a large segment of the ureter must be excised
as a result of radiation stenosis and/or chronic ureteritis, it is
unwise to try to anastomose the remaining stenosed, radiated, and inflamed
ureter to the bladder. Therefore, if the patient's kidney is reasonably
healthy, the surgeon may choose among three procedures: (1) a cutaneous
nephrostomy, (2) a transureteroureterostomy, and (3) a ureteroileoneocystostomy.
This last procedure has the advantage of using nonirradiated materials
in the entire system.

Physiologic Changes. The
most important physiologic changes are that (1) obstruction is taken
away from the ureter and (2) the kidney is allowed to survive. The
loss of a 10-15 cm segment of terminal ileum has few long-term sequelae.
If a longer portion of the ileum is removed, however, vitamin B12
should be administered systemically.

Points of Caution. All diseased ureter should be
removed. The anastomosis of ileum into the renal tract can be made
from the renal pelvis, along the ureter, down to the bladder. Frequently,
this is unnecessary, as the proximal portion of the ureter coming off
the renal pelvis may be nonirradiated and noninflamed. As in all cases
of ureteral surgery, the ureter should be stented with medical grade
Silastic double-J catheters.

Technique

A segment of terminal ileum
is selected. The vascular branches in the mesentery of the ileum
are observed by transillumination prior to transection of the
terminal ileum. An incision is made into the avascular plane
of Treitz medial to the ileocolic artery. The terminal ileum
does not have to be selected; proximal ileum or even terminal
jejunum can be used.

An ileoileostomy is performed either with
sutures or with staples.

All diseased ureter has been removed. In
this particular figure, a stump of ureter is shown coming off
the renal pelvis and out of the bladder. The surgeon should not
hesitate, however, to make a cystostomy in the bladder and to
excise any diseased ureter noted.

The proximal stump of ureter is opened longitudinally
to prevent iris contracture at the anastomotic site. A Silastic-grade
double-J catheter has been inserted up into the renal pelvis.

The segment of ileum is moved into place.
The medical grade Silastic double-J catheter has been brought
through the lumen of the ileum. Anastomosis of the ileum to the
ureter is made with interrupted synthetic absorbable suture.

The Silastic double-J catheter
is inserted down the distal portion of the ileum into the bladder.

The ileum is shown anastomosed to the distal
ureter. The Silastic double-J stent is in place. A Jackson-Pratt
suction drain is placed adjacent to the anastomosis. Both the
Jackson-Pratt suction drain and the stent can be removed in 2-3
weeks.